Provider Demographics
NPI:1073797023
Name:CORDOVA, KELLI (RN)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:CORDOVA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5281 NW WICKIUP WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-7160
Mailing Address - Country:US
Mailing Address - Phone:503-430-0625
Mailing Address - Fax:
Practice Address - Street 1:5281 NW WICKIUP WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-7160
Practice Address - Country:US
Practice Address - Phone:503-430-0625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine